UPHP

Core Benefits & Cost Sharing

Core Benefits

We want to help keep you healthy. We strive to do that by providing the health care benefits you need, when you need them. Core health care benefits that are covered for all our UPHP MI Coordinated Health members include;

Preventive & Medical Care
Dental, Hearing & Vision
Mental Health Care
Pharmacy

To get a complete list of our benefits, look at the UPHP MI Coordinated Health Member Handbook.

Supplemental Benefits

Upper Peninsula Health Plan MI Coordinated Health has partnered with NationsBenefits® to provide a supplemental over-the-counter (OTC) benefit.

Members will get $42 each month added to their NationsBenefits OTC benefit balance. Members can use their OTC benefit at participating stores using their Prepaid Mastercard® or shop online at NationsBenefits® to get free home delivery on products such as:

Vitamins and dietary supplements
Pain relief
First aid
Bathroom safety and fall prevention
Incontinence supplies
Dental and denture care
And much more

Check products and services eligibility
View available balance and purchase history
Update account information
Find participating stores

or view the OTC Product Catalog.

If you have questions, need help with the Benefits Pro® Portal, or need help with placing an order, please call UPHP MI Coordinated Health at 1-877-349-9324 (TTY: 711) Monday through Friday from 8 a.m. to 9 p.m. Eastern Time. The call is free.

This card cannot be used to pay for products that are not eligible. Product exclusions include alcohol, tobacco, firearms, and gift cards. If you would like to buy items that are not eligible, you will need to use another form of payment. Any unused funds at the end of the month will carry over to the next month. The last day to spend your funds is December 31, 2026. Any unspent funds will not carry forward into 2027.

Transportation

You can request transportation assistance online at www.uphp.com/transportation or by calling UPHP Transportation at 1-877-349-9324 (TTY: 711). UPHP can arrange assistance in the form of mileage reimbursement or ride assistance.

Annual Notice of Changes

Every fall, Upper Peninsula Health Plan (UPHP) MI Coordinated Health provides our Medicare members with an Annual Notice of Changes booklet. It tells you about the changes to your benefits and costs that will go into effect in January of the upcoming plan year.

To decide what is best for you, review the UPHP MI Coordinated Health Annual Notice of Changes below and compare it with the benefits and costs of other Medicare health plans in your area, as well as the benefits and costs of Original Medicare.

2026 UPHP MI Coordinated Health Annual Notice of Changes

Cost Sharing

Below is a list of your out-of-pocket costs:

Cost

Plan Premium

Yearly Part B Deductible Amount

Yearly Part D Deductible Amount

Medical Maximum Out-of-Pocket Limit

Part D Drug Maximum Out-of-Pocket Limit

$2100

Medical Copayments

There are no copays for medical services under this plan. See the benefits chart in Chapter 4 of the UPHP MI Coordinated Health Member Handbook to learn about your benefits.

Coinsurance

There is no coinsurance for medical services under this plan. See the benefits chart in Chapter 4 of the UPHP MI Coordinated Health Member Handbook to learn more about your benefits.

Patient Pay Amount

If you reside in a nursing facility you may be responsible for a patient pay amount. See the benefits chart in Chapter 4 of the UPHP MI Coordinated Health Member Handbook to learn more about the patient pay amount.

Over-the-Counter Drug and Non-Drug Copay

Medicaid Benefit Drug Copay

Medicare Part B

Part D Drugs: Initial Coverage Stage

Generic Drug Copay*

$0, $1.60 or $5.10

Brand Drug Copay*

$0, $4.90 or $12.65

Part D Drugs: Initial Coverage Stage^¥

Generic Drug Copay

Brand Drug Copay

*The amount you pay depends on the amount of Extra Help you get from Medicare.

^¥The amount you pay once you have reached your Part D Drug Maximum Out-of-Pocket Limit

Bills

If you have paid for a bill that you think Upper Peninsula Health Plan (UPHP) Coordinated Health (HMO D-SNP) should pay some or all of, you can ask us to pay you back. This is called reimbursement.

Below are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received.

When you have received emergency or urgently needed medical care from a provider who is not in our plan’s network.

You can receive emergency services from any provider, whether or not the provider is a part of our network. When you receive emergency or urgently needed care from a provider who is not part of our network, you are only responsible for paying your share of the cost, not for the entire cost. You should ask the provider to bill the plan for our share of the cost.

If you pay the entire amount yourself at the time you receive the care, you need to ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made.
To make sure you are giving us all the information we need to make a decision, you can fill out our UPHP Claim Reimbursement Form to make your request for payment.
At times you may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made.
- If the provider is owed anything, we will pay the provider directly.
- If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost.

When a network provider sends you a bill you think you should not pay.

Network providers should always bill the plan directly, and ask you only for your share of the cost. But sometimes they make mistakes, and ask you to pay more than your share.

Whenever you get a bill from a network provider that you think is more than you should pay, send us the bill. We will contact the provider directly and resolve the billing problem.
If you have already paid a bill to a network provider, but you feel that you paid too much, send us the bill along with documentation of any payment you have made. You should ask us to pay you back the difference between the amount you paid and the amount you owed under the plan.
To make sure you are giving us all the information we need to make a decision, you can fill out our UPHP Claim Reimbursement Form to make your request for payment.

If you are retroactively enrolled in our plan.

Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first day of enrollment has already passed. The enrollment date may even have occurred last year.)

If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services or drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us to handle the reimbursement.

Please contact UPHP Customer Service for additional information about how to ask us to pay you back and deadlines for making your request.

When you use an out-of-network pharmacy to get a prescription filled.

If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. (We cover prescriptions filled at out-of-network pharmacies only in a few special situations.) Please refer to the UPHP MI Coordinated Health Member Handbook to learn more.

Save your prescription receipt and send a copy to us when you ask us to pay you back for our share of the cost. A cash register receipt will not be accepted.

When you pay the full cost for a prescription because you do not have your plan membership card with you.

If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or to look up your plan enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself.

Save your prescription receipt and send a copy to us when you ask us to pay you back for our share of the cost. A cash register receipt will not be accepted.

When you pay the full cost for a prescription in other situations.

You may pay the full cost of the prescription because you find that the drug is not covered for some reason.

For example, the drug may not be on the plan’s formulary or it could have a requirement or restriction that you did not know about or do not think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it.
Save your prescription receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost of the drug.

When you get a Part D vaccine at a provider’s office or clinic

If you get a Part D vaccine from your provider’s office or clinic, instead of a pharmacy, they may ask you to pay them for the cost of the vaccine instead of billing your Part D benefit directly. You can ask us to pay you back for our share of the cost of the vaccine. Save your invoice and send us a copy, following the instructions below for Pharmacy Requests. Please refer to the UPHP MI Coordinated Health Member Handbook to learn more.

Copies of bills and/or receipts may be mailed to:

For Medical Requests:
Upper Peninsula Health Plan
853 West Washington Street
Marquette, MI 49855

To make sure you are giving us all the information we need to make a decision, you can fill out our UPHP Claim Reimbursement Form to make your request for payment.

For Pharmacy Requests:

Express Scripts
ATTN: Medicare Part D
PO Box 52023
Phoenix, AZ 85082

Fax: 1-608-741-5483

To make sure you are giving Express Scripts^® all the information they need to make a decision, you can fill out the Medicare Part D Prescription Drug Claim/Direct Member Reimbursement Form to make your request for payment.

If you have questions, call UPHP Customer Service at 1-877-349-9324 (TTY: 711), Monday through Friday from 8 a.m. to 9 p.m. Eastern time. The call is free

Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan is a new payment option that UPHP offers to help you manage your out-of-pocket costs for your Part D drugs. This plan allows you to spread your drug costs over monthly payments for the calendar year (January–December). It might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs. When you fill a prescription for a Part D drug, you won’t pay your pharmacy (including mail order and specialty pharmacies). Instead, you’ll get a bill each month from Express Scripts, on behalf of UPHP MI Coordinated Health. All plans offer this payment option and participation is voluntary. There’s no cost to participate or interest charges under this payment plan.

You’re most likely to benefit from participating in the Medicare Prescription Payment Plan if you have high drug costs earlier in the calendar year.

This payment option may not be the best choice for you if:

You get or are eligible for Extra Help from Medicare.
Your yearly drug costs are low.
Your drug costs are the same each month.
You’re considering signing up for the payment option late in the calendar year (after September).
You don’t want to change how you pay for your drugs.
You get or are eligible for a Medicare Savings Program.
You get help paying for your drugs from other organizations, like a State
Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage

If you have questions, or to opt in or out of this payment plan at any time, call Express Scripts® Medicare Prescription Payment Plan Customer Service at 1-866-845-1803 (TTY: 1-800-716-3231). Agents can take your call 24 hours a day.

Other ways to enroll:

Enroll online
Enroll by mail – coming soon

If we receive your request during the plan year, we will contact you within 24 hours to ask for more information or let you know our decision. If we receive your request before the plan year starts, we will contact you within 10 calendar days or within the calendar days before your plan enrollment starts, whichever is shorter. You may ask for an urgent (or “fast”) retroactive election if you have urgent drug fills for which you paid your share of the cost before your program request was received and approved. An urgent retroactive request will be processed if both the following conditions are met:

You believe that a delay in filling the drug due to the 24-hour timeframe required to process the request may cause you harm; and
You request retroactive election within 72 hours of the date and time the urgent drug was filled at the pharmacy.

If you don’t agree with our decision or would like to make a complaint about the payment plan, see Chapter 9 of the Member Handbook.

Helpful links:

Medicare.gov: What’s the Medicare Prescription Payment Plan? | Medicare
Medicare.gov: Before using this payment option | Medicare
Medicare.gov: Will this payment option help me? | Medicare
Medicare.gov: Using this payment option | Medicare
Medicare.gov Fact Sheet: What’s the Medicare Prescription Payment Plan?
Monthly Payment Calculator
- Use this calculator to estimate your monthly payments under this payment plan.
- See the gov Fact Sheet for examples of how a monthly bill is calculated.
Medicare Prescription Payment Plan Member Portal